Colo-anal Anastomosis Using a Lone Star Retractor System
Karandikar S*, Rajneesh N**, Masoud A***
*Heart of England Foundation NHS trust, Birmingham, Heartlands Hospital Birmingham, UK
**St Johns Medical College Hospital, Bangalore, Karnataka, India
***Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan, UK
Running Title: Colo-anal anastomosis using Lone Star retractor
Key Words: Anastomosis, retractor, Lone Star
Article type: Case Report
Address for Correspondence: Dr. Sharad Karandikar Consultant General and Colorectal Surgeon
Heart of England Foundation NHS trust Birmingham Heartlands Hospital
Birmingham, UK, B9 5SS.
Abstract
The Lone Star retractor system, a self-retaining, latex free retractor system, has been used in colorectal surgery, gynecology, and urology in the perineal region. We present this case to highlight the ease with which a hand sewn colo-anal anastomosis is possible using the Lone Star retractor.
Introduction
The Lone Star retractor system is a self-retaining, latex free retractor system. The retractor ring is placed over the incision and the first four elastic stays are positioned into the tissue’s edge in directly opposing quadrants, using gentle tension. The counter-traction of the elastic stays stabilizes the retractor system. It is available as a reusable and disposable system. The retractor is used in colorectal surgery, gynecology, and urology in the perineal region.
The traditional retractors which have been shown to compromise sphincter function. The Lone Star gives excellent exposure without the stretch on the sphincter complex as it effaces the anal canal. The colorectal surgeon would find this system useful for complex perianal fistula surgery (advancement flap), rectal prolapse surgery (Delormes operation or Altemeier procedure) and hand sewn colo-anal or ileo-anal pouch anastomosis.
The Lone Star retractor system can be adapted to the perineum of individual patients owing to its adjustable ring. The surgeon may retract the dentate line from any desired angle by repositioning or adding elastic stays. The elastic stay hooks are available as single or double hooks and may be used in place of assistants employing traditional hand-held retractors. Available in a variety of sizes, the stay hooks provide precise retraction for superficial and deep work.
The case highlights the ease with which a hand sewn coloanal anastomosis is possible using the Lone star retractor.
Case Report
A sixty eight year old female patient presented with rectal bleeding and mucous discharge per rectum. She had good internal and external sphincter control clinically. At colonoscopy she was found to have an adenomatous field change involving the entire rectum up to the dentate line. Histology suggested this to be moderate to high-grade dysplasia. Computed Tomography and Magnetic Resonance Imaging confirmed the lesion to be involving only the rectum.
Considering that the pathology was benign, she underwent a restorative procedure. A restorative anterior resection with a disconnection at the dentate line was performed with a temporary ileostomy. This was subsequently closed with a colo-anal anastomosis using the Lone Star retractor system. Postoperatively, the patient had reasonable anorectal function and with preservation of continence.
Figure 1: Placing the Lone Star reactor to expose the dentate line and lower rectal mucosa
1
Figure 2: Circumferential disconnection of the rectal mucosa (held in the Babcock’s) at the dentate line2
Figure 3: Specimen has been resected.Diathermy points to the internal sphincter. Hooks are placed at dentate line.
3
Figure 4: Decending Colon pouch (held in the Bobcock’s) ready fot the colo-anal anastomosis
4
Discussion
The technique for an ultra low colo-anal hand sewn anastomosis is made simple by the use of a Lone Star retractor system as highlighted in the clinical photos.
Figure 1 demonstrates the placement and the exposure achieved by the retractor. The disconnection of the lower rectal mucosa from the dentate line under vision is demonstrated in figure 2.
The demonstration of the sphincter anatomy is achieved and demonstrated in figure 3.
Lastly, figure 4 demonstrates the exposure achieved to start the colo-anal anastomosis.
Summary
In summary, complex anal surgery can be made simple and safe by appropriate instrumentation. The Lone Star retractor system is a valuable addition to the colorectal surgeon’s armamentarium.
References:
Zimmerman DD, Gosselink MP, Hop WC, et al. Impact of two different types of anal retractor on fecal continence after fistula repair: a prospective, randomized, clinical trial. Dis Colon Rectum 2003; 46:1674-1679.
Van Tets W F, Kuijpers J H, Tran K, et al. Influence of Parks’ anal retractor on anal sphincter pressures.
Dis Colon Rectum 1997; 40: 1042-1045.
Carriero A, Dal Borgo P, Pucciani F. Stapled mucosal prolapsectomy for haemorrhoidal prolapse with Lone Star Retractor System. Tech Coloproctol 2001; 5: 41-46.
Zimmerman DD, Briel JW, Gosselink MP, et al. Anocutaneous advancement flap repair of transsphincteric fistulas. Dis Colon Rectum 2001; 44:1474- 1480